Lower Respiratory Problems

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber

After change-of-shift report, which patient should the nurse assess first?

A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled B. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath C. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes D. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

B. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? A. Age B. Blood pressure C. Respiratory rate D. O2 saturation E. Presence of confusion F. Blood urea nitrogen (BUN) level

Age, Blood pressure, Respiratory Rate, Presence of Confusion, Blood Urea Nitrogen (BUN) Level

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

Assist the patient to splint the chest when coughing Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?

Auscultate for breath sounds The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provide

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? A. Chest x-ray via stretcher B. Blood cultures from two sites C. Ciprofloxacin (Cipro) 400 mg IV D. Acetaminophen (Tylenol) rectal suppository

Blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

Continue to monitor the collection device Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every 8 hours.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D. Elevate the head of the bed to a semi-Fowler's position.

Elevate the head of the bed to a semi-Fowler's Position The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?

Frequent use of incentive spirometer

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

I will continue to perform deep breathing and coughing exercises at home. Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

I will use the incentive spirometer every hour or two during the day Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? A. Hyperthermia related to infectious illness B. Impaired transfer ability related to weakness C. Ineffective airway clearance related to thick secretions D. Impaired gas exchange related to respiratory congestion

Impaired gas exchange related to respiratory congestion All of these nursing diagnoses are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?

Increase the prescribed O2 flow rate Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

O2 Saturation is 88% O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

Observe for distended neck veins Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxical Chest Movement Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

Patient reports a decrease in exertional dyspnea. Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? A. Codeine B. Guaifenesin C. Acetaminophen (Tylenol) D. Piperacillin/tazobactam (Zosyn)

Piperacillin (Zosyn) Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

Which action should the nurse plan to prevent aspiration in a high-risk patient?

Place a patient with altered consciousness in a side-lying position

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions in a private hospital room

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting up on the side of the bed When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?

Pulmonary Vascular Resistance PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?

Require the use of protective equipment

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

Tape a nonporous dressing on three sides over the wound. The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?

The epoprostenol (Flolan) infusion is disconnected. The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

The patient's white blood cell (WBC) count is 9000 u/L The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patient's bed to 15 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak Cough Effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.